Clinical Policy: Cosmetic And Reconstructive Surgery
Clinical Policy: Cosmetic and Reconstructive SurgeryReference Number: HNCA.CP.MP.169Effective Date: 10/04Last Review Date: 011/20Coding ImplicationsRevision LogSee Important Reminder at the end of this policy for important regulatory and legalinformation.DescriptionMedical necessity criteria for cosmetic or reconstructive surgery. Please note that these aresubject to state and federal mandates as well as member benefits and evidence of coverageguidelines. Please refer to the reconstructive surgery mandates for California for more detail.Not all cosmetic procedures are listed in this policy. The Medical Director has the final decisionto deny coverage for services deemed cosmetic in nature and not medically necessary.Policy/CriteriaI. It is the policy of Health Net of California that reconstructive surgery is medically necessaryfor any of the following indications:A. Surgery to correct congenital defects that cause significant functional deficiencies orchallenges of any body part, developmental abnormalities, degeneration defects, trauma,infections, tumors or diseaseB. Facial surgery to correct congenital, acquired, traumatic, or developmental anomalies thatmay not result in functional impairment, bur are so severely disfiguring as to meritconsideration for corrective surgery (e.g. the craniofacial anomalies associated withCrouzon’s Syndrome and Treacher-Collins SyndromeC. Surgery in connection with treatment of severe burns.D. Surgery for therapeutic purposes which coincidentally also serve some cosmetic purposeE. Insertion or injection of prosthetic material for significant deformity from disease ortraumaF. Pulsed dye laser therapy for the treatment of congenital port wine stains of the face orneckG. The intense pulsed light sources (IPLS; e.g., PhotoDerm VL) for medically appropriatetreatment of congenital port wine stains when there is documented evidence of failure oftreatment with pulsed dye laser therapyH. Excision/treatment of tattoos of traumatic or therapeutic originsI. Surgical treatment of congenital hemangiomas when any of the following are met:1.The hemangioma is interfering with the functionality of the nose, eyes, ears, lips orlarynx;2.The hemangioma is symptomatic (e.g., bleeding, painful, ulcerated, recurrentinfection); or3.The hemangioma is associated with Kasaback-Merritt Syndrome;4.The hemangioma is pedunculatedJ. Repair/revision of scars, including keloids, originating from a covered surgical ortherapeutic procedure or an accidental injury that are associated with significantsymptoms of pain, burning or itching which cannot effectively be treated with non-Page 1 of 9
CLINICAL POLICYCosmetic and Reconstructive Surgerynarcotic analgesics and/or steroid injections, that interferes with normal bodily functionsuch as the movement of a joint, or are unstable and have a history of intermittentbreakdownK. Low-dose radiation (superficial or interstitial) as an adjunctive therapy immediatelyfollowing excisional surgery (within 7 days) in the treatment of keloids when criteria forkeloid removal are metL. Testicular prostheses for replacement of congenitally absent testes, or testes lost due todisease, injury, or surgeryM. Excision of lipoma(s) when located in an area(s) of repeated touch or pressure withdocumentation of tenderness and/or inhibition of the patient’s ability to perform activitiesof daily livingN. Skin tag removal when located in an area of friction with documentation of repeatedirritation and bleedingO. External facial prosthesis when there is loss or absence of facial tissue due to disease,trauma, surgery, or a congenital defect, regardless of whether or not the facial prosthesisrestores functionP. Chin, cheek, or jaw reshaping (facial implants or soft tissue augmentation) fordeformities of the maxilla or mandible resulting from trauma or disease and to bedistinguished from orthognathic surgeryQ. Punch graft hair transplant may be considered reconstructive when it is performed tocorrect permanent hair loss that is clearly caused by disease or injury (e.g., eyebrow(s)replacement following a burn injury or tumor removal as in craniotomy).R. Otoplasty (ear pinning) for absent or deformed ears such as microtia (small, abnormallyshaped or absent external ears) or anotia (total absence of the external ear and auditorycanal) with functional deficiencies resulting from trauma, surgery, disease or congenitaldefect when performed to improve hearing by directing sound into the ear canal.S. Post-mastectomy or post significant lumpectomy resulting in asymmetry: breastreconstruction, including nipple reconstruction, tattooing and surgery on contralateralbreast to restore symmetry;T. Removal of a breast implant, periprosthetic capsulotomy or capsulectomy for mechanicalcomplications of breast prosthesis such as rupture, extrusion, painful capsular contracturewith disfigurement, inflammatory reaction to implant, siliconoma, granuloma, interferencewith diagnosis of breast cancerU. Breast implant for Poland’s syndrome (congenital absence of breast)V. Repair of breast asymmetry due to trauma.W. Use of FDA-approved facial dermal injections (Sculptra , Radiesse ) or autologous fattransfers for HIV-associated wasting for facial lipodystrophy syndrome (FLS)II. It is the policy of Health Net of California that cosmetic surgery is not medically necessaryand generally not a covered benefit when performed to improve a patient’s normalappearance and self-esteem. (Note that there may be exceptions when procedures are relatedto gender dysphoria treatment.) These procedures include, but are not limited to:A. Cosmetic surgery performed purely for the purpose of enhancing one’s appearance,and/or expenses incurred in connection with such surgeryPage 2 of 9
CLINICAL POLICYCosmetic and Reconstructive SurgeryB. Cosmetic surgery performed to treat psychiatric or emotional distress, problems ordisordersD. Dermabrasion, chemical peel, liquid nitrogen, skin grafting, dry ice or CO2 snow unlessotherwise specifiedE. Flesh color tattooing for the treatment of port wine stains, hemangiomas or birth marksF. The intense pulsed light sources (IPLS; e.g., PhotoDerm VL) as initial therapy fortreatment of port wine stains, hemangiomas, spider angiomas, cherry angiomas and facialtelangiectasiasG. Septoplasty performed solely to improve the patient’s appearance in the absence of anysigns and/or symptoms of functional respiratory abnormalitiesH. Rhinoplasty for external nasal deformity not due to trauma or disease (non coveredservices)I. Mastopexy (breast lift) to treat sagging of the breastJ. Removal or revision of a breast implant for non-medical reasonsK. Surgery to correct a condition of “moon face” which developed as a side effect ofcortisone therapyL. Otoplasty (ear pinning) for lop ears, bat ears or prominent or protruding ears withoutM. Injection of any filling material (collagen) including but not limited to collagen, fat orother autologous or foreign material grafts unless treatment for facial lypodystrophyN. SalabrasionO. Rhytidectomy of face (face lift) for aging skinP. Removal of fatty tissue by lipectomy (i.e. suction-assisted liposuction, lipoplasty)Q. Excision excessive skin, thigh, leg, hip, buttock, arm, forearm or hand, submental fat pad,other areasR. Electrolysis or laser hair removal unless specified (ie gender affirming procedures)S. Correction of inverted nipplesT. Sclerosing of spider veins and/or telangiectasisU. Excision/correction of glabellar frown linesV. Hair transplants to correct male pattern baldness (alopecia) or age related hair thinning inwomenW. Ear piercingX. Facial rejuvenation/plumping/collagen or fat injectionsY. Buttock or thigh liftsAA. Neck TucksBB. Chin implant to improve ones appearanceCC. Epidural chemical peels used to photoaged skin, wrinkles, or acne scarringDD. Cryotherapy for acneEE.Dermal chemical peel used as treatment of end-stage acne scarringFF.Dermabrasion for wrinkling, pigmentation or severe acne scarringGG.Chemical exfoliation for acneHH. Laser resurfacing for wrinkling, aging skin, or telangectasias resulting from rosaceaII.Insertion or injection of prosthetic material to replace absent adipose tissueJJ. Augmentation or enlargement (augmentation Mammoplasty) of small but otherwisenormal breasts unless part of gender affirming surgeryKK.Phalloplasty (penis enlargement)LL.Diastasis recti repair in the absence of a true midline hernia without evidence ofPage 3 of 9
CLINICAL POLICYCosmetic and Reconstructive Surgerycurrent or potential incarceration, volvulus, or strangulation of bowelMM. Excision/treatment of decorative tattoosNN. Repair/revision of vaccination scarsOO.Reduction of labia minorPP.Collagen implant (e.g. Zyderm)QQ. Earlobe repair to close a stretched pierce holeRR. Surgery to change the appearance of a child with Downs SyndromeSS. VestibuloplastyTT. Vermilionectomy (lip shave), with mucosal advancementBackgroundReconstructive surgery is performed on abnormal structures of the body, caused by congenitaldefects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumorsor disease. It is generally performed to improve the functioning of a body part and may or maynot restore a normal appearance. Functional impairment is a health condition in which thenormal function of a part of the body or organ system is less than age appropriate at full capacity,such as decreased range of motion, diminished eyesight or hearing, etc. that variably impactsactivities of daily living.Cosmetic surgery is performed to reshape normal structures of the body in order to improve theappearance and self-esteem of a patient. It is generally not considered medically necessary. Thispolicy will provide general guidelines as to when cosmetic and reconstructive surgery is or is notmedically necessary.Coding ImplicationsThis clinical policy references Current Procedural Terminology (CPT ). CPT is a registeredtrademark of the American Medical Association. All CPT codes and descriptions are copyrighted2015, American Medical Association. All rights reserved. CPT codes and CPT descriptions arefrom the current manuals and those included herein are not intended to be all-inclusive and areincluded for informational purposes only. Codes referenced in this clinical policy are forinformational purposes only. Inclusion or exclusion of any codes does not guarantee coverage.Providers should reference the most up-to-date sources of professional coding guidance prior tothe submission of claims for reimbursement of covered services.Codes related to this policy: May not be an all inclusive listCPT val of skin tags, multiple fibrocutaneous tags, any area; up to andincluding 15 lesionsShaving of epidermal or dermal lesionsExcision of benign lesionsTattooing, intradermal, introduction of insoluble opaque pigments to correctcolor defects of skin, including micropigmentation; 6.0 sq cm or lessPage 4 of 9
CLINICAL POLICYCosmetic and Reconstructive SurgeryCPT 171081725017380DescriptionTattooing, intradermal, introduction of insoluble opaque pigments to correctcolor defects of skin, including micropigmentation; 6.1 to 20.0 sq cmTattooing, intradermal, introduction of insoluble opaque pigments to correctcolor defects of skin, including micropigmentation; each additional 20.0 sq cmor part thereof (List separately in addition to code for primary procedure)Subcutaneous injection or filling material (e.g collagen); 1 cc or lessSubcutaneous injection or filling material (e.g., collagen); 1.1 cc to 5.0 ccSubcutaneous injection or filling material (e.g., collagen); 5.1 cc to 10.0 ccSubcutaneous injection or filling material (e.g., collagen); over 10.0 ccInsertion of tissue expander(s)for other than breast, including subsequentexpansionPunch graft for hair transplant; 1 to 15 punch graftsPunch graft for hair transplant; more than 15 punch graftsDermabrasion, total face (e.g. for acne scarring, fine wrinkling, rhytids,general keratosis)Dermabrasion, segmental, faceDermabrasion, regional, other than faceDermabrasion, superficial, any site (e.g.tattoo removal)Abrasion; single lesion (e.g. keratosis, scar)Abrasion; each additional 4 lesions or lessChemical peel, facial; epidermalChemical peel, facial; dermalChemical peel, nonfacial; epidermalChemical peel, nonfacial; dermalBlepharoplasty, lower eyelidBlepharoplasty, lower eyelid with extensive herniated fat padBlepharoplasty, upper eyelidBlepharoplasty, upper eyelid with excessive skin weighing down lidRhytidectomyExcision, excessive skin and subcutaneous tissue (includes lipectomy);abdomen, infraumbilical panniculectomyExcision, excessive skin and subcutaneous tissue (includes lipectomy),abdomen (e.g. abdominoplasty) (includes umbilical transposition and fascialplacationDestruction of cutaneous vascular proliferative lesions (e.g., laser technique);less than 10 sq cmDestruction of cutaneous vascular proliferative lesions (e.g., laser technique);10.0 to 50.0 sq cmDestruction of cutaneous vascular proliferative lesions (e.g., laser technique);over 50.0 sq cmChemical cauterization of granulation tissue (proud flesh, sinus or fistula)Electrolysis epilation, each 30 minutesPage 5 of 9
CLINICAL POLICYCosmetic and Reconstructive SurgeryCPT hinoplasty, primary; including major septal repairRhinoplasty, secondary; intermediate revision (bony work with osteotomies)Rhinoplasty, secondary, major revision (bony tip work and osteotomies)Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate,including columellar lengthening; tip onlyRhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate,including columellar lengthening, tip, septum, osteotomiesSeptoplasty or submucous resection, with or without cartilage scorring,contouring or replacement with graftVermilionectomy (lip shave), with mucosal advancement.Vestibuloplasty; anteriorVestibuloplasty; posterior, unilateralVestibuloplasty; posterior, bilateralVestibuloplasty; entire archVestibuloplasty; complex (including ridge extension, muscle repositioning)Otoplasty, protruding ear, with or withoutsize reductionUnlisted special dermatological service or procedureDescriptionICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10-CMDescriptionCodeL30.4Erythema intertrigoM95.4Acquired deformity of chest and ribQ16.0-Q16.9Congenital malformations of ear causing impairment of hearingQ17.2MicrotiaQ67.6Pectus excavatumQ75.1Crouzon’s SyndromeQ75.4Treacher-Collins SyndromeQ79.8Poland syndromeQ82.5Congenital non-neoplastic nevusD17.0-D17.9Benign lipomatous neoplasmD18.01Hemangioma of skin and subcutaneous tissueH02.401Ptosis of eyelidH02.439L90.5Scar condition and fibrosis of skinL91.0Hypertrophic scarL91.8Other hypertrophic disorders of the skinQ55.0Absence and aplasia of testisZ85.3Personal history of malignant neoplasm of breastPage 6 of 9
CLINICAL POLICYCosmetic and Reconstructive Acquired absence of eyeAcquired absence of breast and nippleReviews, Revisions, and ApprovalsDatePolicy adopted from Health Net NMP169 Cosmetic and ReconstructiveSurgeryAnnual review, no changesAdded language to refer to California reconstructive surgery mandates andalso noted that for the treatment of gender dysphoria, there may beexceptions to some procedures generally considered cosmetic. AddedreferencesRemoved Nasal Surgery (S) and section on pectus excavatum (T) and Nussprocedure (U) from medically necessary section since all have InterqualcriteriaAdded W to medically necessary section – treatment for faciallipodystrophyReviewed, no 5/2005/2011/2011/20References1. California Health and Safety Code 1367.63 requires health care service plans to coverreconstructive surgery. “Reconstructive surgery” means surgery performed to correct orrepair abnormal structures of the body caused by congenital defects, developmentalabnormalities, trauma, infection, tumors, or disease to do either of the following:(1) To improve function or(2) To create a normal appearance, to the extent possible.California Health and Safety Code 1367.6 requires treatment for breast cancer to coverprosthetic devices or reconstructive surgery to restore and achieve symmetry for the patientincident to a mastectomy2. American Society of Plastic And Reconstructive Surgeons. Position Paper. BreastReconstruction. June 1999.3. American Society of Plastic and Reconstructive Surgeons. Position Paper. CutaneousLaser Surgery. January 1999.4. American Society of Plastic and Reconstructive Surgeons. Position Paper, Ear Deformity:Prominent Ears. January 1998.5. American Society of Plastic and Reconstructive Surgeons. Position Paper, Reoperation ofWomen with Breast Implants. June 1994.6. Institute for Clinical Systems Improvement (ISCI). Acne management. Bloomington(MN): Institute for Clinical Systems Improvement (ICSI); 2003.7. Hayes. Health Technology Brief. Nuss Procedure for Pectus Excavatum in Children.December 31, 2010. Archived Jan 2014Page 7 of 9
CLINICAL POLICYCosmetic and Reconstructive Surgery8. National Institute for Health and Clinical Excellence (NICE). Placement of pectus bar forpectus excavatum (also known as MIRPE or the Nuss procedure). August 26, 2009.9. American Society of Plastic Surgeons (ASPS): Recommended Insurance CoverageCriteria for Third-Party Payers; Abdominoplasty and Panniculectomy Unrelated toObestiy or Massive Weight Loss. dominoplasty-and-Panniculectomy.pdf10. American Society of Plastic Surgeons. Physician’s guide to cosmetic surgery overview.11. DeLong MR, Tandon VJ, Rudkin GH, Da Lio AL. Latissimus Dorsi Flap BreastReconstruction-A Nationwide Inpatient Sample Review. Ann Plast Surg. 2017 Mar 24.12. Goldstein BG, Goldstein AO. Keloids and hypertrophic scars. In: UpToDate. DellavilleRP, Levy ML (Ed), UpToDate, Waltham, MA. Accessed 3/13/18.13. Razdan SN, Cordeiro PG, Albornoz CR, et al. National Breast Reconstruction Utilizationin the Setting of Postmastectomy Radiotherapy. J Reconstr Microsurg. 2017 Feb 2414. Ilonzo N, Tsang A, Tsantes S, et al. Breast reconstruction after mastectomy: A ten-yearanalysis of trends and immediate postoperative outcomes. Breast. 2017 Apr;32:7-12. doi:10.1016/j.breast.2016.11.023. Epub 2016 Dec 16.15. California Health and Safety Code 1367.63 and California Insurance Code 10123.8816. CMS: National Coverage Determination (NCD) for Dermal Injections for the Treatmentof Facial Lipodystrophy Syndrome (LDS) (250.5)Important ReminderThis clinical policy has been developed by appropriately experienced and licensed health careprofessionals based on a review and consideration of currently available generally acceptedstandards of medical practice; peer-reviewed medical literature; government agency/programapproval status; evidence-based guidelines and positions of leading national health professionalorganizations; views of physicians practicing in relevant clinical areas affected by this clinicalpolicy; and other available clinical information. The Health Plan makes no representations andaccepts no liability with respect to the content of any external information used or relied upon indeveloping this clinical policy. This clinical policy is consistent with standards of medicalpractice current at the time that this clinical policy was approved. “Health Plan” means a healthplan that has adopted this clinical policy and that is operated or administered, in whole or in part,by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.The purpose of t
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the appearance and self-esteem of a patient. It is generally not considered medically necessary. This policy will provide general guidelines as to when cosmetic and reconstructive surgery is or is not medically necessary. Coding Implications
indirectly effect on cosmetic surgery. Keywords: Body image, Self-esteem ,Conformity, Cosmetic surgery; 1. Introduction If we look at the history of the rise of cosmetic surgery and how coming into, we clearly understand that cosmetic surgery was reconstructive surgery for congenital lesions and later, due to the high impact that has on beauty .
cosmetic procedures. As well as the social factors mentioned above, economic drivers include increasing affordability of cosmetic procedures, and the commercially driven nature of the industry itself. Most cosmetic procedures are provided in the private sector, and the connection between cosmetic procedures and the beauty industry makes this sector
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease.
Cosmetic surgery may be surgical or nonsurgical, but is primarily performed in order to improve a patient’s appearance or self- esteem. Reconstructive surgery is a covered benefit while cos metic surgery is not covered.
Cosmetic services are defined as services which are used to improve a person's appearance, but not their functionality. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Their condition is not impairing their ability to participate in daily activities and routines.
1Breast reduction is categorized as reconstructive surgery and not cosmetic. While it may have some aesthetic benefit, the overall need for this surgery is for the health of the patient and to make physical changes to the breast to fit the patient's lifestyle or health needs. The top cosmetic procedures patients are seeking in 2021-2022
as cosmetic (unless substantiating documentation is received that would otherwise indicate that the purpose of the procedure is to restore or improve bodily function or is otherwise medically necessary). The plan reserves the right to deny coverage for other procedures that are cosmetic and not medically necessary.
EUROPEAN BANKING SYSTEM DECEMBER 2020. RISK SSESSMENT TE EREN NKIN SSTEM 3 Contents Abbreviations 8 Executive summary 10 Introduction 12 1. Macroeconomic environment and market sentiment 13 2. Asset side 22 2.1. Assets: volume and composition 22 2.2. Asset-quality trends 32 3. Liability side: funding and liquidity 44 3.1. Funding 44 3.2. Liquidity 52 4. Capital 57 5. Profitability 65 6 .
